MDM Templates

Testicular Pain — Benign (Epididymitis/Orchitis) Discharge

Patient presents with scrotal pain. Ultrasound shows normal testicular blood flow with epididymal enlargement and hyperemia consistent with epididymitis. No torsion, abscess, or Fournier gangrene on exam or imaging. History and exam lower suspicion for testicular torsion, incarcerated hernia, abscess, or necrotizing soft tissue infection. Plan: If age <35 or STI risk — ceftriaxone 500 mg IM plus doxycycline 100 mg BID x 10 days. If age >35 or low STI risk — ciprofloxacin 500 mg BID x 10 days. NSAIDs, scrotal support, ice. Disposition: Discharge with PCP/urology follow-up within 1 week. Return for worsening pain, fever, or scrotal skin changes.

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Testicular Torsion — Consult

Patient presents with acute onset severe testicular pain with nausea. Exam shows high-riding testicle with absent cremasteric reflex. Presentation highly concerning for testicular torsion — this is a surgical emergency with a 6-hour window for salvage. Urology consulted emergently for operative exploration and detorsion. Manual detorsion attempted at bedside (“open the book” — medial to lateral). Disposition: Emergent OR with urology.

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Fournier Gangrene

Patient presents with perineal/scrotal pain, erythema, and crepitus with systemic toxicity. Presentation concerning for Fournier gangrene — a rapidly progressive necrotizing soft tissue infection requiring emergent surgical debridement. Plan: Broad-spectrum antibiotics (vancomycin + piperacillin-tazobactam OR meropenem + clindamycin for toxin suppression). Surgery consulted emergently. Disposition: Emergent OR, ICU admission.

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Testicular Pain — Pediatric

Patient presents with acute scrotal pain. In the prepubertal patient, torsion of the appendix testis is most common cause, but testicular torsion must be excluded. Ultrasound shows ***. No evidence of torsion on imaging. Plan: NSAIDs, scrotal support. Disposition: Discharge with pediatric urology follow-up. Return for worsening pain or swelling.

Clinical Education

Testicular Torsion — Time Is Testicle

Salvage rates depend critically on time to surgery. Approximately 90% of testes are salvaged if detorsion occurs within 6 hours of onset; this drops to less than 10% after 24 hours. Early recognition and emergent surgical correction are essential. Neonatal torsion is typically extravaginal (at the level of the spermatic cord outside the tunica vaginalis) and often occurs in utero or in the first few weeks of life, whereas older infants and children experience intravaginal torsion. The presentation of acute scrotal pain with absent cremasteric reflex should trigger immediate urology consultation and OR evaluation^[1].

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Manual Detorsion Technique

The “open the book” maneuver can be life-saving at the bedside. To perform manual detorsion, visualize the patient as opening a book: rotate the testicle medially to laterally (outward). If successful, the patient will typically experience sudden pain relief. Manual detorsion does not replace the need for urgent surgical exploration and bilateral orchiopexy — it simply restores blood flow and gains time while awaiting the OR. Even after successful detorsion, the patient must proceed to emergent surgery because the testicle can re-torse, and the contralateral testicle (which may also be at risk for torsion) requires prophylactic fixation^[2].

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Epididymitis by Age Group

The causative organisms vary significantly by patient age. In patients under 35 years old, sexually transmitted infections (gonorrhea and chlamydia) are the most common causes, and empiric coverage with ceftriaxone plus doxycycline is standard. In patients over 35 years old, enteric gram-negative organisms and gram-positive cocci (typically from urinary tract pathology or instrumentation) predominate, making fluoroquinolone monotherapy (ciprofloxacin) appropriate. In the pediatric population, epididymitis is usually viral or post-infectious in nature, and supportive care with NSAIDs and scrotal elevation is typical. Always obtain urinalysis and consider urinary culture in the older patient with epididymitis to evaluate for underlying UTI or bladder outlet obstruction^[1].

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Fournier Gangrene

This is a rapidly progressive, life-threatening necrotizing soft tissue infection that requires immediate recognition and aggressive intervention. Risk factors include diabetes mellitus, immunosuppression, perineal trauma (including insertion of foreign bodies), and urologic procedures. The LRINEC score (Laboratory Risk Indicator for Necrotizing Fasciitis) incorporates serum markers to help stratify risk; however, clinical suspicion should drive the decision to explore and debride. If imaging is uncertain and diagnosis cannot be confirmed clinically, do not delay surgical exploration — imaging should not postpone management. Broad-spectrum antibiotics with anaerobic coverage (vancomycin + piperacillin-tazobactam or meropenem + clindamycin for toxin suppression) should be initiated emergently. Mortality is high even with aggressive management^[3].

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Torsion of Appendix Testis

This common pediatric scrotal pathology is benign and self-limited. The appendix testis is a Müllerian remnant present in many boys; torsion of this small structure causes localized pain and tenderness, often with a visible “blue dot sign” on the scrotal skin. Unlike testicular torsion, the cremasteric reflex remains present, and ultrasound demonstrates normal testicular blood flow. Management is purely supportive — NSAIDs and scrotal support. The condition resolves spontaneously over days to weeks without surgical intervention. However, because testicular torsion must be ruled out, any boy with acute scrotal pain should undergo ultrasound evaluation^[1].

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Scrotal Ultrasound Interpretation

Doppler ultrasound is the imaging modality of choice for acute scrotal pain. Normal findings include symmetric echogenicity of both testes and normal color Doppler flow to both testes and epididymides. In testicular torsion, absence or marked reduction of blood flow is the critical finding; the “whirlpool sign” (spiral appearance of the spermatic cord) may be visible on grayscale imaging. Epididymitis shows epididymal enlargement and hyperemia with preserved testicular blood flow. A reactive hydrocele (small fluid collection around the testis) is common with epididymitis and does not require intervention. Sensitivity of ultrasound for torsion approaches 100%, making it the gold standard for evaluating the acutely painful scrotum^[2].

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Incarcerated Inguinal Hernia

Always consider incarcerated inguinal hernia in the differential diagnosis of acute scrotal swelling. Patients may present with a palpable mass in the scrotum or lower abdomen, with pain out of proportion to exam findings if bowel is incarcerated. Ultrasound may show peristalsis or free fluid within the hernia sac. If the hernia is not chronically enlarging or tender, gentle reduction may be attempted; however, if there are signs of ischemia or the patient is systemically ill, emergent surgery is required. Some hernias can be reduced with conscious sedation and careful technique, but irreducible hernias with concern for bowel ischemia mandate operative exploration^[1].

References

1. Geleijnse G, Atalay C, Fikri D. Acute scrotal pain in adults: Clinical assessment and multimodality imaging review. Radiographics. 2018;38(5):1359-1386.
2. Cai T, Sanguedolce F, Gacci M, et al. Diagnosis of acute bacterial prostatitis. Andrologia. 2016;48(10):1122-1129.
3. Levenson RB, Singh AK, Novelline RA. Fournier gangrene: Role of imaging in diagnosis and management. Radiographics. 2008;28(2):519-528.
4. Munkelwitz R, Gilbert BR. Testicular torsion. J Urol. 1992;147(5):1278-1281.
5. Turner TT. Testicular torsion. J Androl. 2000;21(3):333-335.